Friday, June 20, 2014

Medicaid Managed Care: Recovery Moves to the Mainstream

By
Briana Gilmore, Director of Public Policy and Advocacy, New York
Association of Psychiatric Rehabilitation Services (NYAPRS)

Learn
More About the Trends That Will Affect You

Big
changes are coming soon to New York’s Medicaid system. Services are
being overhauled to emphasize quality and outcomes, and new services
are being added to ensure that Medicaid is paying for the most
cost-effective and valued treatment. Why is this good news? These
changes will be beneficial to all Medicaid consumers who use
behavioral health (BH) services. In fact, New York will implement
changes in 2015 that emphasize recovery-oriented BH services in
unprecedented ways.

This
change started in 2011 when Governor Cuomo instituted the Medicaid
Redesign Team, a planning system that looked at outcomes of the
Medicaid system and made targeted changes. The goal was to build off
reforms central to the Affordable Care Act, with the mission of
reducing overall cost while improving outcomes and quality care.
Policy makers quickly realized that achieving this would be
particularly challenging for the BH system.

New
York is transitioning the BH system because recovery-focused services
not only improve quality and outcomes, but also save money. This plan
also raises the bar for providers, many of whom have long been funded
based on how often people come to programs rather than demonstrated
improvements in people’s lives. In order to achieve this
transition, the plan targets social determinants of well-being such
as housing, employment, education, and family connections.

DOH,
OMH, and OASAS have decided to accomplish this by moving to a system
of managed care that will be expected to improve the coordination and
impact of care.

Managed
care isn’t new, and many who are Medicaid eligible already have
physical health and pharmacy services paid for by a Managed Care
Organization (MCO). In 2015, every person in New York State who is
eligible for Medicaid will also have their mental health and
addiction services coordinated and paid for by an MCO.

If
you are already enrolled in an MCO, you will receive all of your
benefits from the same plan. If you’re not enrolled, you will have
to choose an MCO. If you’re not sure about which plan to choose or
if you want to switch, you can access an enrollment broker to help
you do so.

Medicaid
recipients who have used a lot of mental health and addiction in the
past will be enrolled in a Health and Recovery Plan (HARP) that will
offer and coordinate a greater amount of those services.

Thanks
to advocacy from NYAPRS (New York Association of Psychiatric
Rehabilitation Services) and other advocacy groups, HARPs are
required to offer services that have never been Medicaid funded,
including peer services, crisis respite, supported employment and
education, family supports, non-medical transportation, and
self-directed care.

Some
of these services, like crisis respite, will be available as needed.
But others will be offered based on goals you express during
treatment planning with a care manager, such as transitional
employment. This will be a major change for many people; instead of
just being offered service options, people in HARPs will be asked
what their recovery goals are and what supports they need to get
there. It will take time to build a system that understands how to do
this, but it will also take time before all community members are
able to articulate what their goals and preferences are.

Ideally,
that is what care management is all about. Health Homes are
established throughout the state to provide care management that
excels at helping people access services they really want and need,
including community supports like housing and wellness activities.
Health Homes are just networks of providers organized by a central
agency; they aren’t a place, but have care managers that provide
outreach in community settings.

Health
Homes are operating with mixed success. Their capabilities depend on
the strength of their provider network and ability of staff to truly
understand the needs of our community, including cultural norms and
preferences. Care Management will be a big part of the way MCOs
understand and organize services in the future, particularly through
HARPs. MCOs will have to work with Health Homes to ensure each
recipient receives the attention that helps them achieve the best
life possible in the community.

This
historic shift in the way Medicaid is delivered will mean dramatic
improvements in the way the community accesses services that truly
help people recover. But it won’t happen perfectly all at once, and
recipients may have to press for better attention from care managers,
more appropriate service access, or demand community-based living and
service options. NYAPRS and Medicaid Matters New York, along with
other associations, achieved the inclusion of an ombuds program in
Medicaid Managed Care; an ombuds is an office that can objectively
help resolve complaints and help consumers navigate problems.

Importantly,
this shift is just one of many moving toward a more coordinated
system. People who need nursing home or long-term care services will
also experience changes in services coordination, and eventually
everyone in New York State who has Medicare coverage will elect an
MCO. Stay updated through community forums for information about how
benefits you receive are improving and what you can do to advocate
for what you and your peers need.